Hearts, Volume 6, Issue 2 (June 2025) – 7 articles

Background: This study aims to evaluate the impact of critical illness, defined as the need for preoperative intensive care unit (ICU) admission for invasive monitoring or organ support, on cardiac surgery outcomes for patients with acute infective endocarditis (IE). Methods: A retrospective analysis of prospectively collected data from patients treated between 1 January 2017 and 30 May 2024 at a single Australian tertiary cardiothoracic centre was performed. Data were collected from the Australian and New Zealand Cardiothoracic Society (ANZCTS) database and the Australian and New Zealand Intensive Care Adult Patients Database (ANZICS-APD). Results: Among 342 patients who underwent cardiac surgery for IE, 32 (9.4%) were critically ill. The critically ill patients were admitted to the ICU before surgery with a diagnosis of septic or cardiogenic shock, with 86% (n = 30) requiring mechanical ventilation. Compared to the non-critically ill cohort, critically ill patients were more likely to have a history of intravenous drug use (IVDU) (41% vs. 14%, p = 0.03) and a younger age (median age 49 years [42–56] vs. 61 years [44–70], p = 0.03), and although methicillin-sensitive Staphylococcus aureus (MSSA) was the most common causative organism in both groups, it was found significantly more often in the critically ill cohort (66% and 27%, p = 0.001). The median EuroSCORE II was comparable between the groups (2.1 [1.3–10] vs. 2.8 [1.3–5.7], p = 0.69); however, the APACHE III (57 [49–78] vs. 52 [39–67], p = 0.03) and ANZROD scores (0.04 [0.02–0.09] vs. 0.013 [0.004–0.038], p = 0.00002) were significantly higher in the critically ill patients. The overall 30-day mortality rates were similar between the groups (13% vs. 5%, p = 0.60). The median ICU length of stay (LOS) was significantly longer for the critically ill patients (5 days [IQR 2–10 days] vs. 2 days [1–4 days], p = 0.0004), with a similar hospital LOS (23 days [IQR 14–36] vs. 21 days [12–34], p = 0.46). Renal replacement therapy was three times higher in the critically ill (34% vs. 11%, p = 0.0001). Reoperations for bleeding were similar between the groups (16% vs. 11%, p = 0.74). Conclusions: Despite being associated with higher ANZROD and APACHE III scores, a longer ICU length of stay, and higher use of renal replacement therapy, critical illness did not have an impact on the EuroSCORE II, hospital length of stay, or reoperation rates for bleeding or 30-day mortality among patients with IE undergoing cardiac surgery. The lessons from this study will guide and inform the development of better infective endocarditis databases and registries. Full article

Background: Patients with chronic kidney disease (CKD) face an elevated risk of cardiovascular disease (CVD), particularly those with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m². Aims: To assess low-density lipoprotein cholesterol (LDL-C) values and the proportion of pre-dialysis patients achieving national and international targets. Methods: This was a retrospective audit (May–October 2024) of 272 patients aged >18 years attending pre-dialysis clinic (estimated glomerular filtration rate <30 mL/min/1.73 m²) at the Renal Unit, Birmingham Heartlands Hospital. Data on age, sex, ethnicity, body mass index, smoking status, CVD status, hypertension, diabetes, lipids (including LDL-C using the Friedewald and Sampson algorithms) and lipid-lowering therapy were collected from the hospital electronic records. Statistical analyses evaluated factors that were associated with LDL-C (linear/multiple regression) and statin therapy (Chi square). Results: The median (interquartile range) calculated LDL-C values were 2.2 (1.7–2.8) mmol/L and 2.3 (1.7–2.9) mmol/L using the Friedewald and Sampson algorithms respectively. Age and statin therapy were independently associated with LDL-C. Using the Friedewald algorithm, 83.8%, 70.6% and 60.3% did not achieve LDL-C targets of 1.4 mmol/L, 1.8 mmol/L and 2.0 mmol/L respectively, these figures were higher when the Sampson algorithm was applied. Only 18 and 3 of the patients were on ezetimibe and inclisiran respectively, whilst not a single patient was on bempedoic acid or proprotein convertase subtilisin/kexin type 9 inhibitors. Conclusion: Our data highlight deficiencies in the management of LDL-C in advanced CKD. We would recommend greater awareness of LDL-C targets and the use of combination lipid-lowering therapy following optimisation of statin therapy. Full article

Background: Infected aortic aneurysms pose significant therapeutic challenges, given the fragility of infected aneurysmal tissue. Mycotic aneurysms caused by Streptococcus agalactiae are rare and may progress in the absence of classical systemic infection signs. Here, we discuss the surgical management of an unusual presentation of a mycotic aneurysm and its rapid progression with no incremental changes in the patient’s symptoms. Case: A 72-year-old woman presented with subacute general deterioration and back pain. A general workup revealed a mycotic aneurysm of the aortic arch, at the level of the brachiocephalic artery. Initial CT showed a 7 × 5.5 mm pseudoaneurysm that enlarged to 41 × 26 mm within three weeks, despite clinical improvement of her presenting symptoms on antibiotics. Given that the lesion progressed, a staged procedure, consisting of a left carotid–subclavian bypass followed by proximal arch repair, was undertaken with success. Intra-operatively, a completely thrombosed innominate vein was found compressing—and likely tamponading—the pseudoaneurysm, a phenomenon that may have prevented catastrophic rupture. A Dacron graft was sewn end-to-end to the distal ascending aorta; the posterior half of this distal anastomosis incorporated the rim of the innominate artery defect to create a single hemostatic suture line. Conclusions: This case demonstrates a benign initial presentation can degenerate into a catastrophic pseudoaneurysm and how rapidly progressive thoracic infected aneurysms can develop. Heightened clinical acumen is required for accurate diagnosis. Close follow-up is also suggested based on the rapid progression experienced by our patient. Serial imaging, rather than symptomatic or laboratory response alone, should guide the timing of intervention. Full article

Catheter ablation (CA) was found to outperform antiarrhythmic drug therapy (AAD), and it is a key treatment for rhythm control for patients with symptomatic atrial fibrillation (AF). Nevertheless, the procedure’s effectiveness is limited by recurrence rates. Identifying determinants of effective ablation is critical for optimizing patient selection, operative results, and long-term rhythm management strategies. In this state-of-the-art review, we have comprehensively discussed the various factors that can determine the recurrence of AF after a successful CA. Full article

Background/Objectives: The complexity of Minimally Invasive Mitral Valve Surgery (MIMVS) could cause a slow learning curve and potentially patient harm. We thus investigated if a novice mitral valve center encountered difficulties implementing MIMVS. Methods: We investigated seven hundred and forty-eight mitral valve surgery patients, two years before and after MIMVS introduction. Results: We propensity score matched two hundred and sixty elective mitral valve patients for comparison, with one hundred and thirty patients in each group. Surgical- (5.5 vs. 4.3 h), Cardiopulmonary bypass- (180 vs. 102 min) and aortic cross-clamp times (98 vs. 81 min) became longer after MIMVS introduction. One-year mortality and in-hospital outcomes remained unaffected. Hospital length of stay shortened significantly after MIMVS (5 d vs. 7 d; p < 0.001). Conclusions: Adopting MIMVS in a mitral valve center without prior experience in the procedure showed feasibility, equally good outcome and shorter hospital stay when compared to conventional sternotomy. Full article

Adult congenital heart disease (ACHD) represents a significant portion of congenital anomalies, and with improved treatments leading to an increased life expectancy, its prevalence has been increasing over the past few decades. Nonetheless, a considerable number of patients with ACHD require cardiac rhythm management devices during their lifetime. Traditionally, transvenous pacemaker placement has been the standard mode of treatment for these patients. However, some patients with ACHD have anatomical barriers that obscure this mode of treatment. Leadless pacing systems (LPSs) have changed the field of pacing. Currently, two different LPSs are available. In a real-world setting, implanting an LPS in patients after tricuspid valve (TV) surgery seems to be a straightforward procedure with a low risk of complications, with patients showing no valvular dysfunction after the intervention. LPS implantation is an option to avoid device-related complications in patients with previous TV surgery. Moreover, it has been demonstrated that even the jugular approach seems as safe as the femoral approach and could be considered an alternative implantation method for LPSs. The Aveir VR leadless pacemaker is a helix LPS with unique features, such as its capacity as a dual-chamber leadless pacemaker, the ability to map electrical parameters before releasing the device, and its possibility of being retrievable. Hereby, we present the case of Ebstein’s anomaly, atrial septal defect closure, and previous TV surgery with symptomatic intermittent advanced atrioventricular block. This case illustrates that a transjugular approach for LPSs is also feasible in patients with ACHD. Full article

Right heart failure (RHF) is a common manifestation after left ventricular assist device (LVAD) placement and is associated with a high mortality rate. Historically, RV failure requiring an RVAD at the time of LVAD implantation has been associated with an especially high mortality. However, more recently, some studies have shown reasonable outcomes after LVAD implantation even when an RVAD is required, especially if RV failure is recognized early and treated with RV mechanical support. This article analyzes the current trends and studies investigating the use of RVAD placement post-LVAD implantation with an emphasis on the newest devices and treatment paradigms. Full article